Organization
AUTHENTIC LIFE CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TIFFANY RUSSELL (OWNER)
(574) 323-6996
Entity
Organization
Contact information
Practice address
210 E MAIN ST STE 16, NILES, MI 49120-2376
(269) 409-1276
Mailing address
78 SUNSET LN, NILES, MI 49120-9344
(574) 323-6996
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Enumeration date
07/28/2020
Last updated
07/28/2020
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